Contributors BF, DK, EB and AS conceived the idea for this systematic review and together with ZM developed the methods. BF and ZM undertook
the searches, and BF and DK undertook study selection, critical appraisal and data extraction, with AS acting as an arbiter.
BF and DK led the drafting of the manuscript, with AS and ZM commenting on and editing several drafts. AS was the Principal
Investigator. All authors approved the final manuscript.

Accepted 1 January 2012

Published Online First 10 February 2012

Abstract

Background Patient histories in electronic health records currently exist mainly in free text format thereby limiting the possibility
that decision support technology may contribute to the accuracy and timeliness of clinical diagnoses. Structuring and/or coding
make patient histories potentially computable.

Methods A systematic review was undertaken of the benefits and risks of structuring and/or coding patient history by searching nine
international databases for published and unpublished studies over the period 1990–2010. The focus was on the current patient
history, defined as information reported by a patient or the patient's caregiver about the patient's present health situation
and health status. Findings were synthesised through a theoretically based textural analysis.

Findings Of the 9207 potentially eligible papers identified, 10 studies satisfied the eligibility criteria. There was evidence of
a modest number of benefits associated with structuring the current patient history, including obtaining more complete clinical
histories, improved accuracy of patient self-documented histories, and better associated decision-making by professionals.
However, no studies demonstrated any resulting improvements in patient care or outcomes. When more detailed records were obtained
through the use of a structured format no attempt was made to confirm if this additional information was clinically useful.
No studies investigated possible risks associated with structuring the patient history. No studies examined coding of the
patient history.

Conclusions There is an insufficient evidence base for sound policy making on the benefits and risks of structuring and/or coding patient
history. The authors suggest this field of enquiry warrants further investigation given the interest in use of decision support
technology to aid diagnoses.

Footnotes

Funding This work was funded by the NHS CFH Evaluation Programme (NHS CFHEP 009). The views expressed in this publication are those
of the authors and not necessarily those of the NHS, the NHS CFH Evaluation Programme or the Department of Health.